Request A Free Consultationcat-right

INCORRECT AIR MATTRESS SETTING AND IMPROPER POSITIONING CAUSES FALL – LEADS TO DEATH

HENDERSON NURSING AND REHABILITATION CENTER

LOCATED: 2500 NORTH ELM STREET, HENDERSON, KY 42420

HENDERSON NURSING AND REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS

LEVEL OF HARM –ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, facility policy review, and review of the Low Air Loss Mattress Manufacturer Instructions; a hospital emergency room Report; and, review of the Hospice Registered Nurse documentation, it was determined the facility failed to ensure the resident’s environment remained free of accident hazards as possible; and adequate supervision and assistive devices were provided to prevent accidents for (1) of six (6) sampled residents (Resident #6).

On [DATE], Resident #6’s Comprehensive Care Plan was updated to include the use of a Low Air Loss Mattress (alternating pressure) with low pressure settings and bolsters, and the need to position the resident in the center of the bed. However, the facility failed to revise the care plan to include what mattress setting was needed for Resident #6 and to position the resident on the center of the mattress.

On [DATE], Resident #6 slid off a specialty Low Air Loss Mattress sustaining an injury to the left side of the face and head which caused swelling and bruising, a large skin tear to the left arm, and a fracture of the humerus. The facility determined the resident was not positioned correctly in the bed. In addition, the facility had care planned Resident #6 for a bed alarm after a fall on [DATE]; however, there was no bed alarm in place at the time of the [DATE] fall to notify staff if the resident needed assistance.

Review of Nursing Note, dated [DATE] at 4:49 AM, revealed Resident #6 was heard yelling from his/her room and was found on the floor between the two (2) beds in the room, laying on his/her left side. Resident #6 was assessed and placed back into bed, and he/she was noted to have bruising and a knot on the left side of the head just above the temple and a large skin tear on his/her left arm below the elbow. Review of the Fall Investigation Work Sheet, dated [DATE], revealed there was no alarm in place at the time of the fall. Further review revealed the facility determined the Certified Nurse Aide (CNA) had failed to ensure the resident was positioned in the center of the bed.

Review of a Nursing Note, dated [DATE] at 6:40 AM, revealed the resident was complaining of pain anytime the resident’s left arm was moved. The Physician was notified and an order was received to obtain an x-ray.

Review of a Nursing Note, dated [DATE] at 1:45 PM, revealed the resident had a fracture to the upper left arm, and the resident’s family wanted him/her sent to the hospital.

Review of the emergency room (ER) Patient Record of Resident #6, revealed he/she arrived on [DATE] at 1:55 PM and was assessed as having ecchymosis (bruising) and tenderness to the left arm and a skin tear and tenderness and ecchymosis to the left forehead. Review of the ER Physician’s Note revealed he ordered an x-ray of the left arm which revealed a fracture of the proximal humerus (upper arm).

Review of the Hospitalist Discharge Summary, dated [DATE], revealed Resident #6 just wanted his/her pain controlled and if the pain could not be controlled they should just let him/her die. The resident was then admitted to Inpatient Hospice for comfort measures on [DATE] and, expired on [DATE].

Interview with CNA #3, on [DATE] at 2:45 PM, revealed she had provided incontinent care for Resident #6 and turned him/her to the left side, noting the resident was on a specialty constant air flow mattress, but she was not aware of any settings for the mattress. She stated she completed her care and left the room to go across the hall to another resident when not five (5) minutes later, she heard Resident #6 calling for help. CNA #3 re-entered the room to find Resident #6 on the floor, in the position she had left him/her. She stated I don’t know how it happened, the way I had positioned him/her way over towards the left side of the bed, it’s like he/she slid off backwards. CNA #3 stated RN #2 had CNA #7 pick up the resident off the floor and put him/her back in the bed and LPN #1 assessed the resident. CNA #3 stated the resident was not complaining of any pain, but he/she did have a goose egg on his/her left side of head. CNA #3 stated she had not been in serviced on the use of the mattress.

Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 11:25 AM, revealed she was Resident #6’s nurse on [DATE] when he/she was found on the floor beside his/her bed. She stated she didn’t know what happened, we just found him/her on the floor. LPN #1 noted the resident had a goose egg to the left side of his/her head and a skin tear on his/her left elbow.

Interview, on [DATE] at 10:05 AM with the Hospice Nurse Aide State Registered (NASR), revealed she visited Resident #6 three (3) days a week for his/her bath. She stated she talked with him/her at length about how he/her injured his/her head and arm. She stated Resident #6’s exact words to her were, I fell out of bed, I told them I was too close to the edge, they think I’m stupid or something, the bed was slick and oops the next thing I know they were picking me up off the floor.

The DON stated Physician Orders, MARs and TARs should reflect that specifically, and for residents’ safety they should be positioned centered in the bed no matter what type mattress was being used. She further stated she was not aware of Resident #6 ever having an alarm on his/her bed or chair. The DON stated she expected staff to follow the care plans to ensure residents received adequate supervision and assistive devices to prevent accidents.

Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.

Click Here To Request A Free Consultation Today!


One Response to “INCORRECT AIR MATTRESS SETTING AND IMPROPER POSITIONING CAUSES FALL – LEADS TO DEATH”

  1. vivian middleton says:

    This particular facility has been sited so many times, yet nothing is ever done. This is where my Uncle was and each time I visited him (which was every day), I always had to talk to the DON regarding problems with his care. Nothing was ever resolved. Finally, I was able to find another facility to place him. This facility keeps changing owners, yet the quality of care remains the same. I was told that “We have no where else to place the residents. All we can do is continue to investigate and do surveys and fine them when they are NON-COMPLIANT.”..This is so sad. They need to be shut down..

LEAVE A MESSAGE or REQUEST SUPPORT

Your email address will not be published. Required fields are marked *

*

*

*

*

*